Sec. 10.34.35.06. Minimum Requirements for Policies and Procedures

The policies and procedures shall:

A. Be congruent with State regulations and standards of care from accrediting bodies and professional organizations; and

B. Address:

(1) Personnel:

(a) Training and Orientation;

(b) Duties; and

(c) Qualifications;

(2) Security of the facility;

(3) Standards of patient care;

(4) Infection control;

(5) Initial and ongoing home safety assessments;

(6) The provision of patient or caregiver education including, but not limited to:

(a) Drug and therapy administration-specific information and precautions;

(b) Reporting adverse drug reactions;

(c) Reporting side effects;

(d) Infusion pharmacy contact information;

(e) Emergency measures related to:

(i) Changes in patient condition requiring medical intervention; and

(ii) Events which may delay or prevent delivery of pharmaceuticals or nursing care; and

(f) Equipment use and safety.

(7) Patient care operations, including but not limited to:

(a) If applicable, pharmacist checking procedures related to order entry and compounding accuracy;

(b) Therapy-specific monitoring parameters for:

(i) Laboratory testing;

(ii) Appropriate frequency of testing; and

(iii) Patient follow-up; and

(c) Pump, or other patient-use equipment, between-patient cleaning, testing, and preventive maintenance, which include specific:

(i) Procedures and documentation of cleaning, testing and preventive maintenance for patient equipment according to manufacturer’s guidelines; and

(ii) Frequencies for all equipment maintenance activities;

(8) Delivery arrangements;

(9) Patient confidentiality and the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; and

(10) Availability of a pharmacist on call after-hours to respond to:

(a) Pharmacy related patient or caregiver inquiries; and

(b) Medication or supply needs.